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UNIVERSITY OF ST.

LA SALLE
COLLEGE OF MEDICINE
PHYSICAL DIAGNOSIS
SCHOOL YEAR 2017-2018

COMPREHENSIVE ADULT HEALTH HISTORY FORMAT

PART I: (History part…subjective data. Please omit the word PART I, PART II etc in your actual paper)

GENERAL DATA:
Name, age, gender, marital status, nationality, religion, occupation, address, number of admission/s, date
and time of admission

SOURCE OF HISTORY AND RELIABILITY:

CHIEF COMPLAINT: (px’s symptom that prompted admission. Must be short, concise and direct to the
point)

HISTORY OF PRESENT ILLNESS:


In paragraph form and must be in chronological order. Start from the first onset of symptom.
You may use short introductions and continuers.)

(THE SUCCEEDING PARTS SHOULD BE IN OUTLINE FORM)


PAST MEDICAL HISTORY:
Childhood Illnesses:
Adult Illnesses: Medical, surgical, Psychiatric, Allergies, vaccines (include maintenance meds and dose)
should be presented in outline form.
Ex.
1993 - hypertension - highest BP 200/120, usual BP 160/90; maintenance: losartan 50mg/day with poor
compliance
1999 - admitted due to Cerebrovascular accident with left-sided residuals

OB-GYNE HISTORY:
Menarche
Menstrual period: duration, flow, cycle length
OB Score: G1P1 (T-P-A-L)

FAMILY HISTORY:

PERSONAL SOCIAL HISTORY: (include smoking and alcoholic beverage drinking history here.)

REVIEW OF SYSTEMS: (give emphasis on pertinent positives and pertinent negatives)


General: (include percent weight loss within a duration of time and not the kilograms or pounds lost)
Skin:
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular:
Gastrointestinal:
Urinary:
Genital:
Peripheral vascular:
Musculoskeletal:
Psychiatric:
Neurologic:
Hematologic:
Endocrine:

PART II:

COMPREHENSIVE ADULT PHYSICAL EXAMINATION FORMAT

GENERAL SURVEY:
Ex. Patient is awake, conscious, coherent, bed-bound, not in cardiorespiratory distress

VITAL SIGNS: Please arrange your vital signs as follows


BP: HR: RR: TEMP.:
WT: HT: BMI:

SKIN:
HEENT:
NECK:
THORAX AND LUNGS: (same format for the succeeding organ systems)
Inspection
Palpation
Percussion
Auscultation
BREAST AXILLAE:
CARDIOVASCULAR SYSTEM:
ABDOMEN:
EXTREMITIES:
RECTAL/GENITAL EXAM:
NEUROLOGIC EXAM:

PART III:
DIFFERENTIAL DIAGNOSIS (at least 3)
WORKING DIAGNOSIS
BASES FOR THE DIAGNOSIS
From the history
From PE
PART IV:
PLANS:
Diagnostic
Therapeutic
Non-pharmacologic

Example:
GENERAL DATA:
A.B., 56-year old, female, married, Filipino, Roman Catholic, housewife, of Barangay 1, Bacolod City, was
admitted for the 1st time at CLMMRH on June 12, 2012 at 12:30pm.

SOURCE OF HISTORY: Patient


RELIABILITY: 90%

CHIEF COMPLAINT: Epigastric pain

HISTORY OF PRESENT ILLNESS:


Patient was apparently well until one week prior to admission when patient had epigastric pain,
gnawing in character…etcetera
No medications were taken and no consults were made until the day prior to admission when
patient had several episodes of post prandial vomiting amounting to about 150ml. There was persistence
of epigastric pain but the patient only took herbal concoctions.
A few hours prior to admission, patient’s epigastric pain worsened at a pain scale of 10/10 which
prompted the patient to seek consult and hence this admission.